I-45: Endometriosis and Infertility: SurgicalApproaches to Treatment

The quantity of Infertility in woman reproductive age suffering from endometriosis in Russia is from 15% (V. Baskakov) to 38% (Popov A). But the treatment success not exceeding 45-48% (not randomized). And the correlation between prevalence endometriosis rate and PR is absent. Is There a Role For Hormonal Treatment in Endometriosis- Associated Infertility? Suppression of ovarian function to improve fertility in minimal–mild endometriosis is not effective and should not be offered for this indication alone. There is no evidence of its effectiveness in more severe disease. Does Surgery for Minimal–Mild Disease Improve Pregnancy Rates? Ablation of endometriotic lesions plus adhesiolysis to improve is effective compared with diagnostic laparoscopy alone. Does Surgery for Moderate– Severe Disease Improve Pregnancy Rates? The fertility in minimal–mild endometriosis role of surgery in improvingpregnancy rates for moderate-severe disease is uncertain. The effect of surgery for peritoneal disease is small. Excision of rectovaginal lesions is of doubtful value and associated with severe morbidity. First-line surgery for the large ovarian endometriomas seems to be the procedure with the most favorable balance between benefits, harm and costs (http://www.guideline. gov). A practical advantage of surgery is temporary pain relief in symptomatic patients. This may render feasible spontaneous attempts at conception in women who refuse or prefer to postpone IVF (Vercellini P). There are the pitfalls of surgical treatment of endometrios; there are non-adequate surgery for diagnosis and staging and non-adequate first operative procedure. We shouldn’t use high energy to remove the endometriomas, bipolar coagulation (max 30 Watt) and/or suture are more safety.Is In Vitro Fertilisation (IVF) Indicated? IVF is appropriate treatment, especially if tubal function is compromised, if there is also male factor infertility, and/or other treatments have failed. Treatment with a GnRH agonist for 3 to 6 months before IVF in women with endometriosis increases the rate of clinical pregnancy. Diphereline 3,75 mg in Russian clinical practice – effective alternative daily forms medications (immediate release). But IVF PR (pregnancy rate) are lower in women with endometriosis than in those with tubal infertility (I-II st. - 16,6%, III-IV st. - 14,9%, tubal Infertility - 37,4%). According our date (not RCT) SL (super long) Protocol of IVF in case of deep endometriosis increased PR (14% vs 25%).Conclusion: ● The effective of surgery for endometriosis-associated infertility may be overvalued. ● The second surgery for infertility treatment is not effective. It should be better to do IVF. ● Complete and detailed information on risk and benefits of treatment alternatives must be offered to patients, in order to allow unbiased choices between different possible options (Vercellini P. et al, 2009)